_____________________________________ has applied for a position with SCICON, the outdoor school of science and conservation for Tulare County Office of Education. In this capacity the applicant will be working with sixth grade students in a residential setting. The applicant will be responsible for instruction and supervision of the twelve year old students.

Please give careful consideration to the questions listed below. When completed please send to:

Fax to: (559) 539-2643 or Mail to: SCICON, P.O. Box 339 Springville, CA 93265

If you prefer, you may also call at (559) 539-2642 to speak with Rick Mitchell, SCICON Program Director, or Dianne Shew, SCICON Program Specialist, at (559) 539-3513.

Thank you for your time and effort!

INFORMATION ABOUT YOU:

Name of Reference: ______________________________________________________________

Address: _______________________________________________________________________

Phone: (       )_____________________________________

Employed by: ___________________________________________________________________

Position: _______________________________________________________________________

1. How long have you known this applicant? ______________________

2. Indicate the nature of your association with the applicant. ___employer ___supervisor ___ other __________________________

3. In what situations have you observed this person in a teaching role? Do you feel he/she would be an effective educator in an outdoor setting? Explain.

4. Would you place a child under the instruction and supervision of this individual in an outdoor environ- mental camp? ___Yes ___No? Explain.

5. From your observations, would you describe the applicant as a leader or follower? How successful has he/she been at interacting with peers or young people? Explain any problems or concerns.

6. In your opinion, is the applicant a suitable role model for 12 year old youths of both sexes? ___Yes ___No Please explain.

7.

8. Please check those qualities which best describe the applicant. (Check as many as are applicable):

___ Assertive ___ Cheerful ___ Creative ___ Dependable ___ Determined ___ Easy going

___ Empathetic ___ Follower ___ Leader ___ Loyal ___ Moody ___ Outgoing ___ Patient

___ Permissive ___ Private ___ Punitive ___ Quiet ___ Self Starter ___ Serious ___ Shy

___ Hard worker___ Team Player ____ Individualist ____Flexible ____ Rigid ____ Passive

_____ I recommend hiring without reservations.

_____ I recommend hiring with some reservations.

_____ I recommend applicant not be hired.

COMMENTS:_____________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Signature ____________________________________ Date __________________________

rev. 12/99